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Transition andOpportunity

This is a time oftransition andopportunity withinthe AANS/CNSJoint Section onPain. Several newofficers and councilmembers wereelected during the

Section business meeting in April. Dr. JeffreyBrown has completed his term as SectionChairman. On behalf of members of theSection, I thank him for the guidance andcontributions he provided the Section duringhis term. In particular, I acknowledge hisaccomplishments in producing the Section onPain CD-ROM publication, “InterventionalTherapies in Neurosurgical Pain Manage-ment 1999.” In this electronic publication,Dr. Brown and his coeditor, ChristopherChittum, have assembled twenty audio/videolectures from the recent Section on Painsatellite symposium on pain management, inwhich some of the nation’s leading experts inthe field of neurosurgical pain managementdiscuss the most current techniques for thetreatment of pain. The CD-ROM is availablefor purchase through the Section on Pain andthe AANS. The first edition of this CD-ROM, produced by Drs. Brown and Chittumfollowing the 1998 satellite symposium onneurosurgical pain management, receivedoutstanding reviews. It has generated substan-tial interest as an educational tool, not onlywithin neurosurgery but in other disciplinesas well, and has been recognized as a proto-type for future electronic publications. Drs.Brown and Chittum are to be commended for

A A N S / C N S S e c t i o n o n P a i n

October 1999Vol.6 Issue 2

Editor: Kim J. Burchiel, MD, FACSAssistant Editor: Shirley McCartney, PhD

In This Issue…3

Peripheral Nerve Stimula-tion for the Treatment of Occipital Neuralgia

5Of Interest at the 49thAnnual CNS Meeting

6SCS for Refractory Angina

Pectoris

7Pain Patterns in ChronicLow Back Pain compared

to 3D Assessment

8Laminectomy v Percutane-ous Electrode Placement in

27 Patients UndergoingSCS for Intractable Pain

10Faces of Pain: The Expres-

sion of Anguish byClassical Roman Masters of

Marble and Oil

11A Prospective, Random-ized, Controlled Clinical

Trial Comparing Intrathe-cal Narcotic Analgesia to

Standard Medical Manage-ment in Benign Pain

13About the Section on Pain

14Calendar of Events

Message from ChairmanKenneth A. Follett, MD, PhD

NEWSP a i nP a i n

continued on page 2

their tremendous effort in producing thisnovel educational resource.

It is with pleasure that I assume the Chair-manship of the AANS/CNS Joint Section onPain. Jaimie Henderson (St. Louis, MO) hasbeen elected vice-chairman. New ExecutiveCouncil members include John Gorecki(Durham, NC), John Oakley (Seattle, WA), andOren Sagher (Ann Arbor, MI). Michael Munz(Philadelphia, PA) has been selected as the newContinuing Medical Education Liaison forthe Section on Pain. Drs. Giancarlo Barolatand Richard Weiner have completed terms onthe Executive Council. We appreciate thecontributions each of these individuals hasmade to the Section and look forward to theiron-going participation in Section activities.

The Section on Pain is relevant to allneurosurgeons. Pain is the most commonreason that people seek medical attention.Most neurosurgeons do not consider them-selves to be “pain doctors,” and pain, per se, isnot a disorder that most neurosurgeons wantto treat; yet much of what we do as neurosur-geons is pain management because so manyof the disorders we treat present as pain.Neurosurgeons who don’t think of themselvesas “pain doctors” should think for a momentabout their own practices. How many of yourpatients present with a complaint of pain?How many of your patients have pain aftersurgery? How many of your patients takemedications for pain relief? How do youmanage patients with pain when surgery isn’tthe answer?

Because pain cuts across many areas ofneurosurgery, the Section on Pain should be aresource for all neurosurgeons. The Sectionhas worked toward accomplishing this

Kenneth A. Follett, MD, PhD

2 October 1999 ■ PAIN SECTION NEWSLETTER

Chairman’s messagecontinued from front page

Colleagues:

An application for membership in the Joint Sectionon Pain can be found on page 15 of this issue or athttp://www.ohsu.edu/som-neurosurgery/news/membershipapp.html. We encourage you toforward this application to colleagues with interests in

pain management.The goals of the Section are to assure the highest

quality of medical care for the management of patientswith pain problems and to assure an appropriatesocioeconomic and political climate conducive to theeffective and efficient delivery of medical care topatients with pain problems.

purpose through its educational projects and service. At pastAANS and CNS meetings, the Section on Pain has sponsoredsymposia that provide information of fundamental importanceto practicing neurosurgeons, such as management of failedback surgery syndrome, and reviews of medical and legal issuespertaining to long-term opioid use for chronic pain. At themost recent AANS annual meeting, members of the Sectionon Pain directed a practical course pertaining to minimally-invasive procedures for management of spinal pain syndromes.This course had broad appeal to neurosurgeons and generatedan overwhelmingly positive response from participants. TheSection’s satellite symposium on pain management, held inconjunction with the 1999 annual AANS meeting, was offeredto all neurosurgeons interested in expanding their knowledgeabout neurosurgical pain management and also received verypositive evaluations by participants. We will continue workingto meet the needs of neurosurgeons in upcoming symposia atthe CNS 1999 in Boston. Scheduled symposia include aConsultant’s Corner for difficult pain management problems,featuring participants from a variety of neurosurgical disci-plines, and sessions on postoperative pain control, includingassessment of pain in the pediatric population, pain control inthe substance abuse patient, and new approaches to postopera-tive pain management in the lumbar spine surgery patient.

This is a time of transition within the Section as new officersand council members assume their roles. This is also a time ofopportunity. As Chairman, I would like the Section on Pain tobe a section that works for all neurosurgeons. To accomplishthis goal, the Section needs the participation of all neurosur-geons, including those who do not consider themselves to be“pain doctors.” I encourage those of you who are alreadymembers of the Pain Section to be active within the Section.Those of you who are not members should consider joiningthe Section to help us develop programs that will be beneficialto you. Feel free to communicate with Section leaders regard-ing issues of concern about pain and its treatment, and to letus know how the Section on Pain can best serve as a resourceto you and your practice. I can be contacted at [email protected] or 319-356-2771. I welcome your com-ments and suggestions about Section activities and encourageyour active participation in the Section on Pain.

Kenneth A. Follett MD, PhDUniversity of Iowa

CD-ROM:

"Interventional Therapies inthe NeurosurgicalTreatment of Pain"

The Joint Section on Pain has produced a CD-ROM entitled "Interventional Therapies in Neurosur-gical Pain Management". The CD is based on thehighly successful and well-attended Satellite Sympo-sium held preceding the AANS Annual meeting in1998. Each of the twenty-five lectures delivered at thesymposium can be viewed. Speakers' slides aredigitized and synchronized to the audiotaped presen-tations. Slides can be enlarged for clearer study. Onemay take as much time as needed to understand thembest. The lectures can be easily reviewed on anycomputer with a CD-ROM drive. The CD shouldserve as an excellent curriculum for the neurosurgicaltreatment of pain for neurosurgeons with a generalpractice, for those with special interest in pain neuro-surgery and for residents in every training program inneurosurgery. It can be purchased through the JointSection on Pain and the AANS and can also be orderon line athttp://www.aans.org/sections/pain/teaser.html.

A sample presentation, Chronic Pain Typesand Treatment Algorithms by Robert M. Levy, willsoon be available as an example of the CD-ROMcontent.

PAIN SECTION NEWSLETTER ■ October 1999 3

Minimally invasive peripheral nerve stimula-tion for the treatment of occipital neuralgia

INTRODUCTIONOccipital neuralgia (ON) is a chronic pain syndrome charac-terized by lancinating pain extending from the suboccipitalregion to the cranial vertex.1,9,16 The etiology of occipitalneuralgia includes trauma, fibrositis, myositis, fracture of theatlas and compression of the C-2 nerve root, C1-2 arthrosissyndrome, alantoaxial lateral mass osteoarthritis, hypertrophiccervical pachymeningitis, cervical cord tumor, Chiari malfor-mation, and a variety of medical conditions.1,4,6,8,10,16,22,23

Treatment of ON usually involves the use of chronic opioidsand neuromodulators,1,4 but may also include transcutaneouselectrical nerve stimulation, external orthosis, steroid injec-tion, nerve blocks, neurolysis,15,22 neurectomy,17 rhizotomy andganglionotomy,7,10,19,24 C1-C2 fusion,11 and radiofrequencyablation.3

Peripheral nerve stimulation (PNS) has been used for neuropathicpain since 196525 and has been proposed as a treatment for ON.5,12-

14,18,20,21,25,26 We describe the use of a laminectomy-type lead (ResumeIITM ) for the treatment of chronic occipital neuralgia.

CASE HISTORYThe patient is a 44 year old male who suffered from eightyears of occipital neuralgia secondary to direct trauma to theoccipital region. He had not lost consciousness nor did hesuffer any cervical injury. He reported headaches 8-10 timesper day, which were refractory to medical treatment under theguidance of a multidisciplinary pain clinic. Prior occipitalnerve injections provided transient relief of his pain. Neuro-logic examination was normal as were preoperative radio-graphic studies.

continued on page 4Components of Occipital Nerve Stimulator

Figure 1— Quadripolar ResumeII TM lead(Courtesy of Medtronic, Inc., Minneapolis, MN)

Figure 2— ITREL 3 TM Generator.

Michael Oh, MD and Donald Whiting, MD, FACSDepartment of Neurosurgery Allegheny General HospitalPittsburgh, PA

PROCEDUREA two-stage operation for the placement of a RESUME IITM leadand ITREL 3TM generator was performed (Figure 1 and 2, respec-tively). In the first stage, a MedtronicTM peripheral nerve stimulatorwith subcutaneous tunneling was performed under intravenoussedation and local anesthesia (See Figure 3 on page 4).

Intraoperative testing of the peripheral nerve stimulatorprovided complete relief of symptoms. The lead was con-nected to the external generator and the patient had a 24 hourhome trial stimulation with excellent relief of his pain. Thefollowing day, the stimulator was internalized and placed in asubcutaneous pocket in the left infraclavicular region usingintravenous sedation and local anesthesia. The patient wasdischarged to home the same day.

RESULTSThe occipital nerve stimulator was initially set with thefollowing parameters: electrode 1 as positive and electrode 2 asnegative, amplitude 8.0 volts, pulse width 330 microseconds,rate 85 pulses/sec. At 1 month follow-up, he reported 100%relief of pain without paresthesia using the stimulator 78% ofthe time and the amplitude limit was lowered to 5.8 volts Athis 6 month follow-up, his stimulator settings were: electrode1-positive and 2-negative; pulse width-300 msec; rate-85p.p.s.; amplitude limit-2.5 volts; and cycling mode- on-15 sec,off-40 sec, 4-sec soft start. The patient continued to have100% relief of pain symptoms using the stimulator 90% of thetime. He reported no paresthesias and continued to be off ofall pain medications, except a nonsteroidal which he wastaking for arthritic knee pain.


REFERENCES

1. Anthony M: Headache and the greater occipital nerve. Clinical Neurology and Neurosurgery 94:297-301, 19922. Bogduk N: The clinical anatomy of the cervical dorsal rami. Spine 7:319-30, 19823. Blume HG: Radiofrequency denaturation in occipital pain: a new approach in 114 cases.

Adv. Pain Res. Ther. 7:691-8, 19764. Brown CR: Occipital neuralgia: symptoms, diagnosis, and treatment. Practical Periodontics & Aesthetic Dentistry

8:557-558, 19965. Campbell JN, Long DM: Peripheral nerve stimulation in the treatment of intractable pain. J Neurosurg 45:692-9, 19766. Clavel M, Clavel P: Occipital neuralgia secondary to exuberant callus formation: case report.

J Neurosurg 85:1170-1, 19967. Dubuisson D: Treatment of occipital neuralgia by partial posterior rhizotomy at C1-3. J Neurosurg 82:581-586, 19958. Ehni G, Benner B: Occipital neuralgia and the C1-2 arthrosis syndrome. J Neurosurg 61:961-965, 19849. Headache Classification Committee of the International Headache Society. Classification and diagnostic criteria for

headache disorder, cranial neuralgias and facial pain. Cephalgia 8(Suppl 7): 10-73, 198810. Horowitz MB, Yonas H: Occipital neuralgia treated by intradural dorsal nerve root sectioning.

Cephalagia 13:354-60, 1993

DISCUSSIONThere are many reports on the effective treatment of periph-eral neuropathies with peripheral nerve simulation.5,12-

14,18,20,21,25,26 In a recent review,14 peripheral nerve stimulationfor painful neuropathies of nerve injury origin was reported tohave good effect in 82.5%, whereas the response rate in otherkinds of pain were 25-50%.

Only a handful of reports, however, describe the use ofperipheral nerve stimulators for the treatment of occipitalneuralgia.20,21,26 Waisbrod et al.,26 reported on one patient whosuffered from greater occipital neuralgia and had a “very goodresult” from PNS. Picaza et al.20,21 reported on six patientswith ON treated with PNS. Two patients had excellent results,one had a good outcome, two had poor outcomes, and onecase was reported as a failure.

Our patient initially required high intensity stimulation forpain suppression. However, the amplitude limit was decreasedto 8.5 v, 5.0 v, 3.5 v and 2.5 v at the 2 week, 2 month, 4 month,and 6 month visits, respectively. At his 6-month settings, ourpatient has an expected battery life of approximately 4 years.Although late recurrence of pain following PNS is reported tooccur 12-24 months after implantation,21 based on the consis-tently decreasing voltage required in our patient, we expect thathe will have continued pain relief throughout the life of thebattery.

The technique described in this paper is a simple andeffective procedure for the treatment of ON. It is minimallyinvasive, reversible, adaptable, and preserves the option forablative procedures. In contrast, cuff electrodes involvesextensive dissection of the nerve with the possibility of nerveinjury, neuroma, and compression from scar formation, as wellas a longer hospital stay. More invasive procedures, such asdorsal nerve root section, involves risk of injury to vital neuraland vascular structures, and requires 3-4 days of hospitaliza-tion, including one day in the intensive care unit10. Adaptabil-ity of PNS allows therapy to be suited to the individual andadjusted for side effects.

continued on page 5

Placement of Occipital Nerve Stimulator

Figure 3— A 1 cm vertical incision was made 1 cmmedial to the mastoid body, just inferior to thenuchal line. The electrode was then passed througha subcutaneous tunnel extending to the midlineabove the trapezius fascia.

continued from page 3


11. Joseph B, Kumar B: Gallie’s fusion for alantoaxial arthrosis with occipital neuralgia. Spine 19:454-5, 199412. Law JD, Swett J, Kirsch WWM: Retrospective analysis of 22 patients with chronic pain treated by peripheral nerve

stimulation. J Neurosurg 52:482-5, 198013. Long DM: Electrical stimulation for relief of pain of chronic nerve injury. J Neurosurg 39:718-729, 197314. Long DM: The current status of electrical stimulation of the nervous system for the relief of chronic pain. Surgical

Neurol 49:142-44, 199815. Magnusson T, Ragnarsson T, Bjornsson A: Occipital nerve release in patients with whiplash trauma and occipital

neuralgia. Headache 36:32-6, 199616. Merskey H. Classification of chronic pain. Pain (Suppl3): 57, 198617. Murphy JP: Occipital neurectomy in the treatment of headache: Results in 30 cases. Maryland Med J 18:62-66, 196918. Nashold BS Jr, Goldner JL, Mullen JB, Bright DS: Long-term pain control by direct peripheral-nerve stimulation. J Bone

Joint Surg (AM) 64-A:1-10, 198219. Onofrio BM, Campa HK: Evaluation of rhizotomy: Review of 12 years’ experience. J Neurosurg 36:751-5, 197220. Picaza JA, Hunter SE, Cannon BW: Pain suppression: chronic effects: Neurosurg 1:226-227, 197721. Picaza JA, Hunter SE, Cannon BW: Pain suppression by peripheral nerve stimulation: Chronic effects of implanted22. Poletti CE and Sweet WH: Entrapment of the C2 root and ganglion by the alanto-epistrophic ligament: clinical syndrome

and surgical anatomy. Neurosurgery 27:228-291, 199023. Star MJ, Curt JG, and Thorne RP: Alantoaxial lateral mass osteoarthritis: A frequently overlooked cause of severe

occipitocervical pain. Spine 17:71-6, 199224. Steechison MT, Mullin BB: Surgical treatment of greater occipital neuralgia: an appraisal of strategies. Acta Neurochir

131:236-40, 199425. Sweet WH. Control of pain by direct electrical stimulation of peripheral nerves. Clin Neurosurg 23:103-11, 197626. Waisbrod H, Panhans C, Hansen D, Gerbershagen HU: Direct nerve stimulation for painful peripheral neuropathies.

J Bone Joint Surg (Br) 67:470-472, 1985 devices. Appl Neurophsiol 40: 223-234, 1977/78


Section on Pain IConsultants Corner on Pain2:00-5:30 PM

Tuesday, 5 October 1999

Learning Objective: At the conclusion of this sessionparticipants will be able to compare and contrast differentstrategies for management of pain.

2:00-2:50 PM Consultant’s Corner2:50-3:30 PM Oral Posters3:30-4:00 PM Coffee Break with Exhibitors4:00-5:30 PM Open Papers 792-801

Section on Pain IIPostoperative Pain Management in the Neurosurgicalpatient2:00-5:30 PM

Wednesday, 6 October 1999

Of Interest at the CNS49th Annual MeetingOctober 30–November 4, 1999 Boston

Learning Objective: At the conclusion of this sessionparticipants will be able to describe methods of assessing andtreating post operative pain in patients undergoing neurosur-gical procedures.

2:00-2:20 PM Assessing Pain in Pediatric patients2:20-2:30 PM Pain Management Following Spine

Surgery: Epidurally-applied Analgesics2:30-2:40 PM Pain Management for the Substance Abuse

Patient2:40-2:50 PM Discussion2:50-3:30 PM Oral Posters3:30-4:00 PM Coffee Break with Exhibitors4:00-5:30 PM Open Papers 842-851

Section on Pain I Tuesday, 5 October 1999,

4:00-5:30 PM Open Papers 792-801

Ronald Tasker Award792. Motor Cortex Stimulation for Chronic Neurpathic

Pain. Literature Review and Results from aPro-spective Audit. Nikki Maartens, Dawn Carroll,Tipu Aziz, Carole Joint.


Spinal Cord Stimulation for refractoryangina pectoris

In spite of advances in revascularization techniques,pharmacological therapy and risk factor modification,there remains a subset of the coronary population withrefractory angina pectoris (RAP). Patients with refractoryangina pectoris represent an expanding population. It isestimated that in the United States 30,000 such patientsexist; about 2-3 per cardiologist. Most of these patientshave had previous multiple bypass and angioplasty proce-dures. Their continued angina despite these interven-tions, and frequent emergency room visits and hospitaladmissions are often due to small areas of intense ischemiaarrhythmias. These patients are generally somatically andsocially disabled with a poor quality of life and significantlimitations in activities of daily living.

Standard spinal cord stimulation (SCS) techniques havebeen used extensively outside North America for thetreatment of RAP since the 1980’s. The first publication onSCS for angina appeared in 1987. Presently, the numberone indication for SCS in Europe is RAP; the second beingperipheral vascular disease. It has provided angina patientswith increased exercise capacity and time to onset of anginawith reduced ST-segment depression, myocardial ischemiaand intake of nitrates. Extensive research in Europe haseliminated concerns regarding the possible danger ofmasking myocardial infarction with SCS. Over 1000 casesof SCS for RAP have been performed in Europe over thelast two decades.

We have followed two patients (ages 53 and 74) for overone year after implantation of their SCS system for RAP.Both patients had undergone previous multiple revascular-ization procedures and continued to experience dailyangina with frequent emergency room visits prior toimplantation. One patient has a cardiac pacemaker.Using standard percutaneous techniques under localanesthesia, quadripolar electrodes were implanted ap-proaching the C7-T1 epidural space through the T3-T4level. Intraoperative test stimulations were performed toensure stimulation-induced parasthesias in the area of thepatients’ angina prior to implantation of an ITREL-IIIpulse generator in each patient. Because of its highsuccess rate, the major European centers utilizing thesetechniques for RAP have abandoned the use of extendedtrial periods of stimulation through externalized leadsprior to final implantation of the SCS system.

Peter A. Pahapill, MD, PhD, FRCS(C)University of TorontoCanada

Implantation under local anesthesia is well toleratedwith a minimum hospital stay in this subgroup of pa-tients with known increased surgical risks. In our twopatients the number of angina attacks has been reducedby 70%; the duration of attacks by 60%; the intake ofnitrates by 90%; and the emergency room visits havebeen reduced from 1.5 visits per week to zero. Ingeneral, stimulation parameters are initially individual-ized, but then require only minimal adjustments. As longas certain guidelines are followed, SCS can be offered toRAP patients with cardiac pacemakers. Best results areobtained with a multidisciplinary team approach involv-ing both the cardiologist and the neurosurgeon.

Although dramatic improvements in quality of lifeoccur with SCS without concealing myocardial infarc-tion, its mechanism of action is unclear. Considerationhas been given to a descending dorsal column influence,with sympathetic modulation and stimulation-inducedalterations in neurohormones receiving attention aspossible contributors. Pain alleviation with SCS isfundamental as it relieves the symptoms that furtheraggravate and contribute to the vicious pain cycle leadingto worsening myocardial ischemia and thus “breaks thechain of pain”.

Increasing numbers of angina patients with theirassociated escalating costs to the health care system hasstimulated interest in alternate approaches of manage-ment. SCS for RAP is a safe and simple technique thathas enjoyed excellent results in the majority of patientswith minimal cost. As more randomized control studiesare published (1) and results underlying the significantcost benefits of these techniques to health care systemsbecome more available, it is probable that the use of SCSin patients with RAP will increase in North America inthe new millennium.

1. Mannheimer C., Eliasson T., Augusinsson L.E., et.al. Electrical stimulation versus coronary arterybypass surgery in severe angina pectoris. TheESBY study. Circulation 97: 1157-1163, 1998


Pain Patterns in Chronic Low BackPain compared to 3D Assessment

In studies of the incidence and prevalence of low back pain(LBP), it has been identified as the second leading cause ofrestricted activity days and work absenteeism. Data from theNational Center for Health Statistics indicates that chronicdisability resulting from LBP affected 4.8 million Americans.

Acute injury to the lower back demonstrates the link between apatient’s perception of pain and tissue injury. The pain afterimmediate injury results in guarding of the low back during thehealing process. However, those patients with pain of durationmore than 6 months develop a different perception of their painwhich is not linked to the acute tissue injury. It is generallyaccepted that chronic low back pain contributes to the psycho-logical factors manifested as the chronic pain syndrome. Thesepatients sustain progressive physical and emotional deteriorationresulting in depression, anxiety and decreased physical activity. Inorder to understand the patient’s psychosocial dynamics, theassessment of chronic pain must include information on patientpersonality and their perception of the pain.

Pain drawings (PD) have been used clinically to assess theefficacy of pain management as a complement to verbal paindescriptions. It is important to understand how reliable thepatient’s description of severity and location of the pain is andhow it responds to the treatment. Therefore, the main objectiveof the study was to delineate the reliability of PD with concurrentpsychophysical measurement in assessing spatial anatomical paindistribution. We compared simultaneously pre and posttreat-ment PD patterns of chronic low back pain with multidimen-

Congress of NeurologicalSurgeonsAnnual Meeting

Save These Dates!American Association of

NeurologicalSurgeonsAnnualMeeting

sional pain scale (MPS) using an interactive computerprogram.

Patients with chronic low back pain (16 patients, meanduration of pain 43 months, 9 male and 7 female) withoutorganic brain dysfunction were evaluated at the clinic. Patientswere introduced to MPS system for the first time. Then thepatients were asked to assign values to the pain descriptionspresented serially on computer. Each office visit, patients recordthier status in the MPS system, the physician can then analyse thepain rating index based on a geometric calculation. Pain drawingdata was analyzed for trunk, lower extremities and combinationusing a quantification method. Pearson correlation test wascarried out to examine the repeatability for the PD and MPSparameters.

For short term treatment effect during the office visit, trunkPD (p<0.01) showed significantly reduced value which was alsofound at both intensity and sensory dimensions of the MPS scale(p<0.02). However, long term evaluation by trunk PD (p<0.02)did not match with the result of sensory dimension (p>0.17) whileintensity decreased significantly (p<0.03). The correlationcoefficient for pain drawing reliability failed to obtain greatervalue over MPS (PD:0.56±0.02, MPS:0.97±0.05). In our study,the confinement of the PD has been questioned.

In conclusion pain drawing can be an important tool for painintensity measurement, yet not for the sensation of pain inprolonged back pain.

October 30–November 4, 1999 Boston April 8–13, 2000San Francisco

Fernando G. Diaz, MD, PhD and Hun K. Park, MD, PhDDepartment of Neurosurgery/Wayne State UniversityDetroit, MI


Laminectomy v Percutaneous Electrode Placement in 27 Pa-tients Undergoing Spinal Cord Stimulation for Intractable Pain

INTRODUCTIONIncreasing numbers of patients are receiving percutaneouslyplaced electrodes in order to reduce costs and to takeadvantage of minimally invasive techniques. Althoughpercutaneous techniques are associated with several attrac-tive advantages, there is currently no objective evidenceevaluating which electrode systems have better long-termoutcomes. The purpose of this study was to evaluate thelong-term efficacy of spinal cord stimulation (SCS) usingopen laminectomy versus percutaneous-styled electrodes.We reviewed our institutional experience with SCS usingmodern electrode systems over the past 6 years. A compari-son of outcome using modern percutaneous and laminec-tomy electrodes is presented.

METHODSForty-one patients were identified who underwent SCS atDuke University Medical Center between December of1992 and January of 1998. Twenty-four patients (59%) weremale and 17 (41%) were female. All patients were referredfor SCS from a multidisciplinary pain clinic having com-pleted at least 6 months of conservative treatment withphysiotherapy, pain medications and in some cases epiduralinjections. Routine psychological evaluation was performedin all patients prior to treatment.

The majority of patients (59%) were diagnosed withfailed back surgery syndrome (FBSS), followed in numberby complex regional pain syndrome (CRPS) I and II (17%),neuropathic pain syndromes (10%), stroke (2%), and allother etiologies (12%).

All patients were screened with a temporary electrodesystem in order to establish satisfactory relief of pain beforeinternalization of a permanent system. Trial stimulation wasperformed through the use of a percutaneous catheter-typeelectrode (Pisces Quadripolar electrode, Medtronic Corpo-ration, Minneapolis, MN) in 27 patients, and through useof a laminectomy-type electrode (Resume electrode,Medtronic Corporation, Minneapolis, MN) in the other 14patients. Temporary electrodes were tested over a periodranging from 1 to 14 days. During this testing period, painrelief and improvements in activity levels were assessed. Iftrial stimulation reduced the patient’s pain greater than50%, the system was internalized and connected to animplanted subcutaneous pulse generator (ITREL II and III,Medtronic Corporation, Minneapolis, MN).

After screening 41 patients, 27 (66%) proceeded to

JC Leveque, BA, Alan T. Villavicencio, MD and John Gorecki, MDDuke University Medical Center/NeurosurgeryDurham, NC

continued on next page

undergo permanent implantation. Following permanentelectrode placement, patients were examined after sixweeks. Follow-up was then conducted at 3 to 6 monthintervals for the first year and annually thereafter. Allpatients in this study were followed for a minimum of 6months. Pre- and postoperative pain levels were based onthe administration of a visual analog scale (VAS) whichrated pain severity from 0 to 10. A modified outcome scale(Table 1) was used to compare the long-term efficacy ofSCS with other treatment methods reported in the litera-ture such as reoperation in patients with failed back syn-drome. There was no significant difference indemographics between patients who underwent percutane-ous electrode placement when compared to patients whounderwent laminectomy (Table 2).

RESULTSFifteen of the 27 patients (56%) had permanent thoracicelectrodes placed percutaneously and 12 (44%) via laminec-tomy. Pre- and postoperative VAS scores are compared in(Table 3). Visual analog scores decreased an average of 4.6for patients undergoing SCS placement via laminectomy inthe thoracic region (two-tailed t-test, P<0.0001). Patientswho underwent percutaneous placement of thoracic elec-trodes had an average decrease in VAS of 3.1 (two-tailed t-test, P<0.001). Table 4 illustrates the long-term resultsusing a modified outcome scale (defined in Table 2).

One hundred percent of the 12 patients who underwentlaminectomy-styled electrode for SCS in the thoracic regionhad >50% pain relief at long-term follow-up; 90% of thesepatients did not require the use of narcotics (Table 1). Nopatients in this group had what was defined as a poor outcome.Percutaneous electrodes were associated with a good orexcellent outcome in 53% of patients, fair in another 27% andpoor in 21%. Electrodes placed through laminectomy exhib-ited significantly greater pain relief at long-term follow-upwhen compared to percutaneous electrodes as measured bythe 4 tier outcome grading scale (P = 0.02).

There was no mortality directly associated with surgery.There were no episodes of spinal cord compression or injury,bacterial meningitis, or other life-threatening infection.Overall, 16 of the 27 patients (59%) with permanent elec-trodes required a total of 36 repositioning procedures. Therewere slightly more revisions required per patient in the


percutaneously placed electrodes: 1.4 revisions per patientcompared with 1.25 revisions per patient in the laminectomygroup. This difference was not statistically significant.

DISCUSSIONSpinal cord stimulation is a safe and useful, minimallyinvasive procedure for the treatment of chronic pain.Recent technical advances in multichannel systems withhave led to improved clinical results and fewer complica-tions. This study contrasted the long-term clinical outcomeof 27 patients who had undergone permanent SCS utilizingmodern multichannel percutaneous or laminectomy-styled

Table 1—Four Tier Long-Term Outcome Scale

Excellent - pain free or very little remaining pain, offnarcotics

Good - residual pain evident, but significantly improved(>50%) and off narcotics

Fair - residual pain evident, but significantly improved(>50%), using narcotics

Poor - less than 50% pain relief

Table 2—Biographical Information in 27 Patientswho Underwent Placement of PermanentElectrode for SCS

Demographic Laminectomy PercutaneousInformation Electrodes ElectrodesMean Age (range) 50 (39-69) 53 (24-74)FBSS* (%) 6 (50) 9 (60)Causalgia (%) 3 (25) 2 (13)Neuropathic (%) 3 (25) 1 (7)Stroke (%) 0 (0) 1 (7)Other (%) 0 (0) 2 (13)

*FBSS - Failed back surgery syndrome

Table 3—Evaluation of Long-term outcomeUsing a Visual Analog Scale (VAS) in PatientsUndergoing SCS

Laminectomy PercutaneousElectrodes Electrodes

Mean Follow-up (months) 8.6 10.3Total Patients 12 15

Preoperative VAS (range) 8.4 (7-10) 8.5 (6-10)Postoperative VAS (range) 3.8 (3-7) 5.4 (0-10)

Table 4—Evaluation of Long-term OutcomeUsing a Modified Outcome Scale in PatientsUndergoing SCS

Laminectomy PercutaneousElectrodes Electrodes

Mean Follow-up (months) 8.6 10.3Total Patients 12 15Excellent (%) 6 (50) 4 (27)Good (%) 5 (42) 4 (27)Fair (%) 1 (8) 4 (27)Poor (%) 0 (0) 3 (20)

electrodes. The data presented suggests that laminectomy-styled electrodes can be expected to achieve approximately92% good or excellent results and another approximately8% fair in the reduction of pain. Percutaneous electrodeswere associated with more than 50% good or excellentresults and another 25% fair. Although patients were notprospectively randomized to each of the two treatmentarms, laminectomy-styled electrodes appear to be associ-ated with improved long-term effectiveness over thoseplaced percutaneously. These data are currently being usedas a rationale to perform a randomized, controlled study.



Faces of Pain: The Expression of Anguish byClassical Roman Masters of Marble and Oil

Classical art depicts the anguish and joy of Man in carefullyhewn marble or painted oil. In this review the emotion of painas portrayed in Classical Roman, Renaissance and modern artthrough the facial features that connote acute and chronic painis evaluated. Perhaps strongest depiction of acute pain is foundin a panel of the painting, Massacre of the Innocents by Matteodi Giovanni. Painted in 1482, it is located in Siena in the thebeautiful church of Sant’Agostino. Sites such as this were wherethe patients, a word that literally translates as “sufferers” camefor solace. Their beauty likely did provide it. It was here that thestatuary and oil paintings of the great artists were kept. Greekand later Roman sculpture grew out of the traditions of Egyp-tian culture. The figures depicted by the Egyptians lacked theimmediacy of any emotion.

When the Greeks added an element of emotion, it was in thetwisting of the torso and not in the face (even if one were to be

found) as in the well-known “Winged Victoryof the Nike ofSamothrace.” Similarlyin the “Venus de Milo,”the look is for eternityand the emotion is in themovement of the torsonot the face. Da Vinci’sportraiture was latermodeled after thisapproach. How do theeyes and lips of the MonaLisa differ from the

power of Van Gogh’s fierce self-portraits?The earliest portrayal of pain is in a detail of Odysseus using a

fire-sharpened stake to blind the Cyclops Polyphemus, a storyfrom the Odyssey. The image is on a jar painted in Athens thatdates to about 650 BC and is located in the Eleusis, Museum. Itshows the open eyes and mouth and upward gaze that will typifythis emotion. Another vase painting, from 470 B.C., depicts thehunter Actaeon being devoured by his hounds for accidentallyviewing the nude Goddess Artemis. This vase is found in theBoston Museum of Art.

The myth of Laocoon was retold in “The Aeneid” by Virgil.The priest Laocoon had warned the Trojans of the woodenhorse. His warning however interfered with the ill-fated courseof events, infuriating Apollo who sent sea serpents to destroyhim and his sons. The amazing naturalism displayed in the

Jeffrey A. Brown, MDMedical College of OhioToledo, OH

modeling is characteristic of the Hellenistic period. It contraststhe adult body with those of the adolescents and the strainedmuscles of the father making almost superhuman effort to freehimself with the relaxing muscles of his collapse.

The image called“Giant” shows one ofmany defeated and dyingTitans (earth giants) fromthe Great Altar of Zeus,from Pergamon, whichrepresents the mythologi-cal battle of the Gods andGiants. This particulargiant is being bitten by ahuge hunting dogassisting the goddessArtemis. The Altar wasbuilt and sculpted about180-160 BC; the figuresare 2.3 m tall — roughlytwice human scale. TheAltar today is erectedinside the Pergamon museum in Berlin. The Pergamonian artstyle includes the design both of the Laocoon and the “DyingGalatian Soldier,” Greek (and Roman) sculptors were moreinterested in representing movement than emotion or pain.Torture of any kind is rarely shown. The moment before or themoment after a traumatic event is more likely to be represented.The whole body was considered part of a portrait or of arepresentation of a idea. When distorted facial features wererepresented, they were usually part of a genre representation of“humans” who are neither immortals nor respectable citizens.Slaves, peasant farmers, foreigners, and the grotesque ordisabled could be shown “realistically” as comic, drunken, lewd,suffering, or hilarious — because they were not expected toadhere to social standards of appropriate behavior and appear-ance.

The painting “Sosias” is on the tondo (inside) of a wine cup(kylix) and is attributed to the Sosias Painter. It was made about500/490 BC in Athens and shows the Greek hero Achillesbinding a wound in the arm of his friend Patroklos, a scenefrom the Trojan War in Homer’s Iliad. The cup is in thecollection of the Antikensammlung, Berlin. Here is found an

continued on page 12


continued on page 12

A Prospective, Randomized, Controlled Clinical TrialComparing Intrathecal Narcotic Analgesia to StandardMedical Management in Benign Pain

The development of intrathecal narcotic delivery as a treatmentfor chronic pain is a milestone in the history of pain managementthat is as important as the introduction of long acting narcotics oranterolateral cordotomy. There is a well-documented literaturesupporting the use of intrathecal narcotic analgesia (INA) for painassociated with cancer. In contrast all of the literature for intrath-ecal narcotic infusion for benign pain is retrospective. Thisretrospective literature only establishes that chronic intrathecalnarcotic delivery reduces pain to some degree in up to 60% ofpatients for up to 3 years. In spite of the weak supporting data forthe use of INA for benign pain sales figures show that morepumps are being sold to treat benign pain than to treat pain dueto cancer (1249 cancer; 2964 benign). For this reason we initiatedthe first prospective randomized controlled but not blinded studyof intrathecal narcotic analgesia for chronic benign pain.

The following are results obtained from a preliminary review ofboth non-randomized patients from the pilot portion of thisstudy and patients that have been randomized, 46 patients werescreened, 25 patients undertook trial dosing and 21 patients hadpumps implanted.

The goals of the study are to demonstrate better pain control,the safety of, and the cost associated with intraspinal morphine.The study should also determine the incidence of tolerance andprovide supporting data to develop useful patient selectioncriteria. The control group is managed in our multidisciplinarypain clinic and receives all recommended therapies for painmanagement including medication, physical methods, psycho-logical intervention, and anatomical surgery, augmentativesurgery, as well as ablative surgery. Follow up is for five years inorder to document long term efficacy, mechanical complicationsand tolerance. In order to demonstrate a 25% difference betweenthe study and control group with a P value of 0.05 the investiga-tion requires 246 study subjects.

Candidates for the study have suffered from pain for more than6 months and the pain has resulted in a mean pain score of at least7/10. Furthermore patients are only considered for the study ifcorrective surgery such as repeat nerve root decompression orfusion is not indicated, the pain narcotic responsive and the usualmedical management results in unpleasant side effects. Thepatients must be able to read English and be able to travel backand forth to Duke on a monthly basis. A surprising number ofpatients were excluded for psychological reasons (these cases willbe evaluated separately and reported in the future) and a number

of patients could not commit to the follow up necessary for pumprefills.

Pain scores are used as a measure of outcome. The pain score isrecorded by the patient who calls a toll free telephone numberthree times per day for the first four days of each month. Thevoice mail documents the date and time of the call. In this way webelieve that we are collecting more accurate data. A pain diary, analternative method of collecting the same data could be forged inthe office waiting room. The dosing of intrathecal narcotic isbased upon the recorded pain scores. Whenever patients fail tocall in a particular score the missing value is assigned a zero forthe purposes of calculating narcotic refill doses. This is anincentive for the patient to provide the data accurately. Inaddition we collect data about quality of life based upon asubjective four point scoring system also provided by the patient.We collect Beck depression scores, McGill pain questionnaire,and sickness inventory profiles. In addition all health care visitsmade by the patient are documented. A review of these visits willassist in calculating the cost of medical care in the study andcontrol groups.

The mean Verbal Digital Pain score for the entire group ofpatients prior to pump implantation was 9.3. There was nodifference between patients receiving the pump or the controlgroup. With the pump implanted the pain score fell to 3.1. In thecontrol group the pain score fell to 5.6. Statistical analysis was notperformed since all patients were not randomized. Prior tosurgery %% of patients were actively working. At present reviewfor the patients with morphine pumps one quarter are activelyinvolved in gainful employment. This is particularly meaningfulsince many of the patients are over the age of 65.

Patient visits to health care professionals remain frequent dueto the need for refills approximately once per month (45 days fora 30 cc pump delivering 0.5 cc per day or 90 days for a 50 ccpump delivering 0.5 cc per day). Most patients have been able tolimit visits to refill dates. For some patients this means theelimination of frequent emergency room visits associated withepisodic pain exacerbation that occurred before the device wasimplanted. Emergency room visits occurred as frequently as onceper week. The mean annual visit rates were 26 prior to enteringthe study, 20 in the control group, and 13 in the pump group.

The average cost of the pump trial is calculated to be about

John Gorecki, MD, Linda Rubin RN, MPH, Ketan Bulsara, MD and John Pracyk, MDDuke University Medical CenterDurham, NC



early image of chronic pain. The soldier’s head is turneddown. The active wrinkles of facial expression are absent. Theeyelids are hanging, half-closed, mouth partially open, jaw

sagging, as if the energy todemonstrate expression is nowdepleted.

The Dying Galation Soldierrepresents the classic depiction ofennobling chronic pain. Headturned down, expression drained,energy exhausted. It is located inthe Capitolene Museum in Romeand, as mentioned, is likelyPergomonian in origin.

=Another statue found in Romeis known as Spinario, or Boy

Plucking a Thorn from the Foot. It was first named Fedele(Faithful) because it was thought that it was a portrait of

Marcius, a Roman messenger who would not delay his missioneven though he was painfully tortured by a thorn in his foot.The statue stands in the center of room in the Palazzo deiConservatori in Rome atop one of Rome’s seven hills.

The Ugolino group by Carpeaux depicts a horrifying storyfrom Dante’s Inferno. The traitorous Count Ugolino wasimprisoned and sentenced to death by starvation with his sons.Carpeaux depicts the moment when the Count gives up allhope, gnawing at his fingers in despair, as his dying childrenoffer their enfeebled bodies to him for food. They realize thatthey can not survive This imagery emphasises the sufferingquality to human pain, but it is the same theme seen in theLaocoon, suggesting that the greatest pain is that of the parentwho survives while his children die. This is spiritual notphysical pain. In the final stages of anguish, often in thecrucified Christ image, the eyes return to a heavenward gaze.Eyes may remain closed, face reanimated, but there no longer isthe torment of acute or chronic pain.

$3,000. The average cost of pump implantation $13,000. Weare in the process of obtaining accurate data about the cost ofrefills however it has been difficult to document reimbursementlevels for the drug. To date we have had to remove one system forinfection, which obviously impacts the cost of the modality. Noother pump systems have required reoperation, but one othersystem was removed for failure to maintain relief of pain.

Side effects of intrathecal narcotics include nausea, itching, andurinary retention. These side effects are almost universal but self-limited. Elderly patients have much more trouble with nausea,and may need to temporarily accept less than ideal pain controlassociated with lower doses until this subsides.. Catheter fractureis a costly and time-consuming event. Catheter malfunctionshave occurred in our Cancer and Baclofen group but to date notin the benign group.

The effect of INA on testosterone was particulary interestingespecially in the female patients. Almost all women described adesirable increase in libido associated with initial pain controlduring the first 6 months. The initial increased libido was thenfollowed by a progressive decline in libido with a correspondingfall in testosterone level. Male patients did not describe theperiod of increased libido. Nearly all patients endorsed somesexual dysfunction at entry into the study, which often worsenedfollowing intrathecal morphine in male patients.

Not all patients obtained a positive response to intrathecalnarcotics. We currently implant a temporary intrathecal catheterand administer a test bolus of 1mg of morphine (0.5mg for thoseover 55). The patient is observed for 23 hours. A portable

disposable patient controlled external pump delivers a constantinfusion of morphine after the initial bolus dose. Fourteenpercent of the patients failed the trial. Two out of three patientsfailing the trial had central pain which supports the notion thatcentral pain is not narcotic responsive.

Fifteen percent of the patients with implanted pumps failed tomaintain good pain control and one patient had the unit re-moved. Curiously this patient eventually went on to receiverepeat fusion with remarkably good pain relief. This underscoresthe fact that the ability of the surgical community to determinewhich patients are not candidates for anatomical surgery requiresmore sophistication. Infection resulted in the removal of onepump from a patient receiving good pain relief. Another patientlost pain relief after functioning well for 36 months. There was noevidence of catheter malfunction and the patient was offered adrug holiday prior to changing medication which she refused.She committed suicide at another institution.

In conclusion we present the first randomized controlled studyof intrathecal narcotics in benign pain. Pain control can beeffective in 74% of patients over the long term. So far based uponscores, quality of life measures, and work status it appears thatintrathecal narcotic analgesia has a useful role in the treatment ofbenign pain. It may be difficult to prove that this relativelyexpensive treatment is cost effective however much more data isbeing collected to address this important question. More specificselection criteria need to be developed for choosing candidatesfor intrathecal narcotic analgesia from the many patients withchronic pain of benign origin.



The Following books areavailable @

http://www.aans.org/marketpl/amazon.html#pain

Anesthesia and Pain Management for thePediatricianby Lynne R. Ferrari (Editor)Published: May 1999

The Management of Painby Michael A. Ashburn (Editor), Linda J. Rice (Editor)Published: February 1998

Oxford Textbook of Palliative Medicine (OxfordMedical Publications)by Derek Doyle (Editor), Geoffrey W. C. Hanke (Editor),Neil MacDonald (Editor)Published: January 1998

Neural Blockade in Clinical Anesthesia andManagement of Painby Michael J. Cousins (Editor), Phillip BridenbaughPublished: January 1998

Proceedings of the 8th World Congress on Pain(Progress in Pain Research and Management, V. 8)by B.C. Jensen, Troels Staeheli World Congress on Pain1996 VancouverPublished: June 1997

Image-Guided Pain Managementby P. Sebastian Thomas (Editor)Published: January 1997

Neurosurgical Management of Painby Robert M. Levy and Richard B. NorthPublished: November 1996

Purpose:■ In the field of pain management, provides liaison and

involvement with other specialties and organizations.■ Helps communications between AANS and CNS via

joint section status.■ Provides help in resident curricula planning, especially in

the area of pain management.■ Promotes Journal of Neurosurgery and Neurosurgery

manuscript submissions in pain management.■ Fosters international communication and collaboration

in neurosurgical procedures for pain.■ Reaches out to and encourages involvement by part of

neurosurgery somewhat outside mainstream.■ Increases role of neurosurgeon in multidisciplinary field

of pain management.

Founders:Philipp Lippe, MD, Andrew Shetter, MD, Benjamin Crew,MD, Hubert Rosomoff, MD, Joe Seres, MD,Philip Gildenberg, MD, Ronald Young, MD, John Loeser,MD, David Kline, MD, and Frank Mayfield, MD

Officers:Chairman: Kenneth A. Follet, MD, PhDE-mail: [email protected]: 2001

Vice-Chairman: Jaimie M. Henderson, MDE-mail: [email protected]: 2001

Secretary-Treasurer: Kim J. Burchiel, MDE-mail: [email protected]: 2001

Special Activities:■ Consensus Conference on the Neurosurgical Manage-

ment of Pain (1993).■ Education Guidelines for Neurosurgeons in Training

(1995) .■ Development of guidelines for certification in pain manage-

ment with the American Board of Pain Medicine.■ Development of standardized outcome measures with

the American College of Pain Medicine (1995).

Interface/Liaison:■ American Academy of Algology.■ American Pain Society.■ American Academy of Pain Medicine.

Web Site:■ http://www.aans.org/sections/pain/summary.html

About The Section on Pain


Poster Presentation

Techniques and Outcomes of ThoracoscopicSympathectomy

Selected poster from the 67th Annual meeting of theAmerican Association of Neurosurgeons

April 24-29, 1999

J. Patrick Johnson, MD* Samuel Ahn, MD* William Choi,MD+ Jeffrey Masciopinto, MD++

Kee Kim, MD# Aaron Filler, MD* Antonio DeSalles, MD*

* Los Angeles, CA+ Montreal, Canada++ Denver, CO# Sacramento, CA

Thoracic sympathectomy is an important method oftreatment for palmar hyperhidrosis and upper extremitypain disorders. Earlier surgical procedures were highlyinvasive, with known morbidity, acceptable outcomes, andestablished recurrence rates that were the limitations toconsidering surgical treatment. Thorascopic sympathec-tomy is a minimally invasive procedure that allows de-tailed visualization of the sympathetic ganglia and minimapostoperative morbidity; however, outcome studies of thistechnique have been limited.

The authors treated 39 patients who underwent 60thorascopic sympathectomy procedures.

The outcomes in this series were equivalent to previouslyestablished open surgical techniques; however, operativemorbidity rates, hospital stay, and time of return to normalactivity were substantially reduced. Complications andrecurrence of symptoms were also comparable to previousreports. Overall patient satisfaction and willingness torepeat the operative procedure ranged from 66% to 96% inall patients. The hyperhidrosis patients had uniformlyhigh success rates (>90%) whereas the patients with painsyndromes had more variable long-term successful out-comes (i.e. 60%-90%).

Patients and physicians should consider minimallyinvasive thoracoscopic sympathectomy procedures as anoption to treat sympathetically mediated disorders becauseof the reduced morbidity and at least equivalent outcomerates in comparison to previous treatments.

Calendar of Events

8-13 April 200068th American Association of Neurological SurgeonsAnnual Meeting

Location: San Francisco, CAWWW:http://www.aans.org/meetings/aans/summary.html

23-28 September 200050th Congress of Neurological Surgeons Annual Meeting

Location: San Antonio, TXWWW:http://www.aans.org/meetings/cns/

26-29 October 20003rd National Trigeminal Neuralgia Conference

Location: Pittsburgh PA, hostedby the University of Pittsburgh.

2-5 November 200019th Annual Scientific Meeting American Pain Society

Contact: American Pain Society4700 W. Lake AvenueGlenview, IL 60025-1485

Location: Hyatt Regency Atlanta, Atlanta, GAPhone: 847-375-4715 Fax: 847-375-4777E-mail: [email protected]

April 200169th American Association of Neurological SurgeonsAnnual Meeting

Location: TBD

19-22 April 200120th Annual Scientific Meeting American Pain Society

Contact: American Pain Society4700 W. Lake AvenueGlenview, IL 60025-1485

Location: Phoenix, AZPhone: 847-375-4715 Fax: 847-375-4777E-mail: [email protected]

16-21 September 2001XII World Congress of Neurological Surgery

Location: Convention & Exhibition Centre,Sydney, AustraliaWWW:http://www.nsa.on.net/wfns.htm

E-mail: [email protected]

29 September-4 October 200151st Congress of Neurological Surgeons Annual Meeting

Location: San Diego, CA

21-26 September 200252nd Congress of Neurological Surgeons Annual Meeting

Location: Philadelphia, PA

I. Biographical

Name: __________________________________________________________________________________

Birth Place: __________________________________ Birth Date: _______________________________

Citizenship __________________________________

Home Address: _______________________________ Office Address: ____________________________

___________________________________________ ________________________________________

Fax: _________________ Phone: __________________ Fax: __________________ Phone: ______________

II. Category of Membership Requested:

❑ Active ❑ Associate ❑ Corresponding

III. EducationPremedical collegiate education (institutions/dates) _________________________________________________Final degree (institutions/dates) ________________________________________________________________Medical education (institutions/dates)____________________________________________________________Final degree (institutions/dates) ________________________________________________________________Internship or equivalent (institutions/dates) _______________________________________________________Residency or other graduate training (institutions/dates) ______________________________________________Residency training institution __________________________________________________________________Completion (or expected completion) Date _______________________________________________________

IV. Membership, Certification and PracticeAre you now certified by the American Board of Neurological Surgery? ❑ Yes/Year ______ ❑ NoAre you certified in neurosurgery by another examining board? ❑ Yes/Year ______ ❑ No

Are you a member of:❑ American Medical Association❑ Local or regional medical society Name: _________________________________________________❑ State or provincial medical society Name: _________________________________________________❑ American Association of Neurological Surgeons❑ Congress of Neurological Surgeons❑ American Academy of Pain❑ International Association for the Study of Pain❑ American Pain Society

Medical Licensure State ____________________________ Dates ____________________________

Signature _______________________________________ Date _____________________________

Application for Membership

AANS/CNS Section on Pain

Please return completed application to:Section on Pain

Membership Department22 South Washington Street

Park Ridge, IL 60068

AANS/CNS Section on Pain22 South Washington StreetPark Ridge, Illinois 60068-4287

FIRST CLASS

U.S. POSTAGE

PAIDDes Plaines, IL

Permit No. 329

ChairmanKenneth Follett, MD, PhDIowa City, IA

Vice ChairmanJaimie Henderson, MDSt. Louis, MO

Secretary/TreasurerKim Burchiel, MDPortland, OR

Section on Pain Council

Council MembersJohn Gorecki, MDDurham, NC

Michael Munz, MDPhiladelphia, PA

John Oakley, MDSeattle, WA

Richard K. Osenbach, MD,Charleston, SC

Oren Sagher, MDAnn Arbor, MI

Richard Simpson, Jr, MD, PhDHouston, TX

Joint Section on Pain Newsletter

EditorKim J. Burchiel, MD

Assistant EditorShirley McCartney, PhD

Newsletter ContributorsJeffrey Brown, MDFernando Diaz, MD, PhDKenneth Follett, MD, PhDJohn Gorecki, MDJ. Patrick Johnson, MDJ.C. Leveque, BAMichael Oh, MDPeter Pahapill, MD, PhDHun Park, MD, PhDAlan Villavicencio, MDDonald Whiting, MD

This newsletter is sponsored in part by aneducational grant from Medtronic, Inc.http://www.medtronic.com/neuro/apt/whatis.html

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